Michael O Leavitt: I call these speeches The Prologue Series. There is a statue behind the National Archives that I look at nearly every day as I drive between HHS and the White House. The statue, the work of Robert Aitken, is called “The Future.” It depicts a woman looking up to the horizon from a book as if to ponder what she has just read. At the base of the statue are the words from Shakespeare’s The Tempest “What is past is prologue.”

1. From the American People
5
HEALTH DIPLOMACY: FROM THE AMERICAN PEOPLE
Prologue Series
Michael O. Leavitt
Secretary
U.S. Department of Health and Human Services

2. I have come to understand that public service is a generational relay. Many of the
most profound problems are not ours to solve in finality, but rather to incrementally
improve during our temporary stewardship.
Three foundation goals thus form the basis for my public service: to leave things
better than I found them; to plant seeds for the next generation; and to conclude
my work knowing I have given my all.
For nearly sixteen years, my life has evolved in four year terms. I was elected
three times as Governor of Utah. Some of what I consider our accomplishments
were initiated in my first term, but fully matured in my third. Likewise, some seeds
planted in my third term are only now beginning to flower.
Living in four year cycles has taught me the importance of choosing priorities and
impressed the need for urgency. Time passes quickly.
I am currently in my fifth year as a member of President George W. Bush’s Cabinet.
I served first as the Administrator of the Environmental Protection Agency and now
as Secretary of Health and Human Services. The constitutional constraints on the
President’s service imposed limits on what initiatives I might see to completion.
However, I view it as my obligation to lead with a longer horizon in mind.
Over time, I have developed a set of tools useful in keeping a long-term vision in
mind while managing the day-to-day problems. One such tool is establishing a
5,000 Day Vision, with a 500 Day Plan.
The 5,000 Day Vision is our aspiration for various long-term outcomes. The 500 day
plan is more granular, listing what needs to be done now to bring about the larger
vision. Both are recalibrated periodically.
As my stewardship comes to a close, it is time to plant seeds for the next
generation. I intend to write and deliver a series of formal speeches to convey some
of the 5,000 Day Vision and share what I see on our approaching horizon.
I call these speeches The Prologue Series. There is a statue behind the National
Archives that I look at nearly every day as I drive between HHS and the White
House. The statue, the work of Robert Aitken, is called “The Future.” It depicts a
woman looking up to the horizon from a book as if to ponder what she has just
read. At the base of the statue are the words from Shakespeare’s The Tempest
“What is past is prologue.”
I have titled this speech in The Prologue Series: “Health Diplomacy: From the
American People.”
Michael O. Leavitt
Secretary
U.S. Department of Health and Human Services
Speech given on October 17, 2008
in Washington, DC
Prologue Series
Cover image: HHS Photo/Chris Smith

3. Health Diplomacy: From the American People
1
Some months ago, I was in a back alley of New Delhi holding
a little boy across my lap. As a veteran father of five and now a
grandfather of a similar number, I’m well qualified to estimate
the baby’s age at about 18 months. I tipped his head and
administered two drops of polio vaccine into his mouth.
The mother — a small, quiet woman probably in her late
twenties — knelt down to hold the baby’s head. As she did,
our eyes met for just a moment, and there was an unspoken
understanding that parents want to protect their children.
The circumstances of our lives could not have been more
different. I am a member of the President’s Cabinet. I live in
a comfortable townhouse across the Potomac River from our
nation’s capital. She lives in small hut with a dirt floor in a slum.
Our lives intersected for a few minutes, part of a morning I spent
in India reviewing our nation’s support for polio eradication.
Her son is now safe from polio, and the people of that
neighborhood have a different impression about the United
States of America.
Vaccinating a young child for polio in
New Dehli.

4. Health Diplomacy: From the American People
2
A similar wordless communication occurred with a Muslim
father in Zanzibar. I was there to help spray the block walls and
sheetmetal roof of his home for mosquitoes. Our eye-contact
lingered just a second longer than usual. It conveyed gratitude
that his family could be malaria-free.
I have heard HIV/AIDS victims in distant villages of Africa say the
words “U-S-A” with their lips and “thank you” with their eyes.
They knew their lives had been improved because of the anti-
retroviral drugs we provide.
I have seen the effect of impressive, white Navy hospital ships
pulling into ports throughout the world. People arrive hours in
advance and line the streets for blocks, hoping for care. They
leave with a new pair of glasses, or without their persistent
toothache. Others get surgery to repair a debilitating hernia
or cataracts on their eyes. Tens of thousands are served, but
millions know we were there.
Our nation supports economic development, clean-water
projects, and education all over the world. We do joint research,
train soldiers, and provide weapons, food and money.
Ministering to the health-needs of people in hardship is the most
important thing we do.
Why? The language of health is heard by the heart. The richest
and poorest of us are bound together in the uncertainty of our
mortality and the desperation of pain.
Give a mother with HIV/AIDS hope that she can raise her
children, and her gratitude will never wane. Heal a father’s child,
and he will never forget. Give a teen with disfigured legs the
mobility of a wheel chair, and he will praise your name forever.
As Iraqi Prime Minister al-Malaki said to me, “Health is a good
messenger of peace.”
In geopolitics there is a constant struggle to win the hearts
of people. In that battle, deeds speak louder than words. On
the Richter scale of deeds, health makes the needle within a
person’s heart jiggle more than anything else. The language of
health is heard by the heart.
There is a lot of talk these days about the use of “soft power”
and “hard power.” Hard power is military or economic prowess.
I have heard HIV/AIDS victims in
distant villages of Africa say the
words “U-S-A” with their lips and
“thank you” with their eyes.
The language of health is heard
by the heart. The richest and
poorest of us are bound together
in the uncertainty of our mortality
and the desperation of pain.

5. Health Diplomacy: From the American People
3
Soft power nudges in more subtle ways, relying on accumulated
friendship and trust.
Bob Gates, the Secretary of Defense, recently told an audience:
“In short, based on my experience serving seven presidents, as
a former Director of CIA and now as Secretary of Defense, I am
here to make the case for strengthening our capacity to use soft
power and for better integrating it with hard power.”
I hope you will remember three primary things: first, the shared
opinion of the Secretary of Health and Human Services and
the Secretary of Defense that hard power and soft power work
best when integrated; second, the notion that health diplomacy
is the highest-octane soft-power fuel available; third, my series
of specific recommendations on how our new President can
improve our nation’s use of soft power.
Perhaps the greatest testimony of health diplomacy’s unique
power is the degree to which it is used by enemies of
democracy.
For example, in Lebanon, where the legitimate government
has tried but failed to provide adequate health care, Hezbollah,
a political party devoted to terrorism, offers on-the-ground
medical services in poor Shia areas. Hezbollah has clinics and
hospitals throughout the country. In large part, these have
helped establish the group as a political force. Its members
know that war alone will not win people’s trust.
Early in the Iraq War, Al Qaeda targeted the health sector as a
means of discrediting the new government. I was in Iraq in the
fall of 2008. I met with a group of doctors from different parts of
the country. They told me Al Qaeda and other terrorist groups
brutally attacked anyone associated with the health sector. And
it worked!
Of an estimated 34,000 doctors in Iraq in the mid-1990s, at
least 20,000 have left the country. Since 2003, 8,000 doctors
have quit practicing medicine because of fear. More than 2,200
have been killed, and over 250 have been kidnapped. This has
crippled health institutions in Iraq and has lead to corruption,
mismanagement, and terrible conditions. The availability and
quality of health care has diminished, and people’s confidence
in their government has suffered.
Hard power and soft power work
best when integrated.
USNS Comfort at dock for a humanitarian
mission in Panama.

6. Health Diplomacy: From the American People
4
Part of the successful surge strategy has involved greater
support for Iraq’s health sector. The government has a new
health minister. Things are improving.
I met recently with a group of Iraqi doctors who have come to the
U.S. to spend time learning from our health-care community. A
month from now, they will return to Iraq with cellphone numbers
and email addresses of American doctors. They will take with
them enduring relationships that will continue to provide value for
years to come. They will take home a more positive view of the
United States.
The Taliban also know health is important to people. When
health workers heard President Karsi was going to endorse an
anti-polio campaign they asked that he not do so. The local
clinicians know that if it appears important to the government,
the Taliban will attack it. Perhaps for the same reason, they
kidnap and attack health workers.
A man I know in the Health Ministry in Afghanistan was
negotiating with the Taliban for the return of a kidnapped health
worker. To persuade the Taliban leader (who had been an
Islamic cleric), my friend appealed to his cultural sensitivities
by saying, “This man comes from a good family. He has done
nothing but try to help people who are sick. He is not a soldier or
government official.” The Taliban leader replied, “He brings credit
to the government; that is why we took him.”
Health is a legitimizer of governments and ideologies. It also
legitimizes terrorists, revolutionaries, and dictators.
Fidel Castro has little hard power, but he has become a master
at the use of health to generate soft power. He built a series of
medical schools from which he graduates thousands of doctors
and nurses each year. Graduates are deployed in underserved
nations all over the world. Commonly accepted estimates place
the number of Cuban-trained “doctors” around the world at more
than 40,000.
It’s a clever strategy, really. Cuban doctors become important
members of a community. They also become influential political
organizers among the poor and discontented. And, given the
doctors’ small salaries, Castro even makes money on the deal.
Perhaps the greatest testimony
of health diplomacy’s unique
power is the degree to which
it is used by enemies of
democracy.
USNS Comfort staff treats an adult’s teeth
with fluoride.

7. Health Diplomacy: From the American People
5
In terms of land and population, the island country of Cuba is
about the size of the state of Pennsylvania. It has an economy
that’s smaller than that of West Virginia, but it is a major
international player in health diplomacy. In health diplomacy,
Cuba punches bigger than its weight.
Doctors schooled in Cuba are not particularly well-trained. In
many cases, medical associations complain that these doctors
cannot pass the qualifying exams for licensing. However, to the
people in poor, underserved villages in Central America and
Africa, they are a big improvement over nothing.
I’ve met Cuban doctors in El Salvador, Guatemala, Honduras,
Nicaragua, Haiti, Mozambique, and Tanzania. I even came
across the trail of Cuban doctors in Timbuktu. When I was there,
U.S. Army Special Forces personnel told me that there are
teams of Cuban health-care workers permanently working in the
most remote areas of northern Mali, where Al Qaeda trains and
hides.
Recently, a Central American health minister said to me, “We’re
dependent on Cuba to train our doctors. We have no alternative
right now.” It is not a good thing for the United States when
Central American governments are dependent on Cuba.
President Hugo Chavez in Venezuela is adopting the same
model. He is currently building a large medical school to train
doctors for export around the world.
Democracies in many regions of the world are in test-drive
status with their people. Health care is a litmus test of their
government’s legitimacy and effectiveness. Using health care
to discredit democracy is a tactic right out of the insurrectionist
handbook.
In Central America we are at risk of seeing 30 years of progress
toward democracy erode. In country after country in Latin
America, leftist governments are being elected. Health care is
used by left-leaning candidates to stir up discontentment among
the people.
The first time I met Hugo Chavez, he said to me, “What is the
infant mortality rate in Washington, D.C.? In Cuba it is six per
1,000.” I have no idea if that figure is accurate. Neither does
Health is a legitimizer of
governments and ideologies.
It also legitimizes terrorists,
revolutionaries, and dictators.
Health care is a litmus test of
their government’s legitimacy
and effectiveness.

8. Health Diplomacy: From the American People
6
Chavez. Chavez used Washington, D.C.’s rate because it is
higher than the overall U.S. rate, and he was looking to cast a
socialist system in the most favorable light.
I said, “And what is it in Venezuela, Mr. President?” He admitted
it was 23 per 1,000, but he expected it to be lower this year.
Let me acknowledge that some people fundamentally regard
linking humanitarian assistance to foreign-policy goals as a
crass abandonment of sincerity. They think global health should
be about benevolence and feel uncomfortable in measuring the
benefits of health diplomacy.
But we can be benevolent and benefit from it. In fact, it is a
practical necessity to strategically allocate our benevolence to
optimize benefit.
The benefits of health diplomacy go well beyond diplomatic
points. Health diplomacy also benefits our citizens inside the
United States.
Infectious disease is a good example. In the last century, three
pandemic influenzas have struck. The pandemic of 1918 took
more than 50 million lives worldwide, including more than
600,000 in the United States. There have been at least ten
pandemics in the past 300 years. There is no reason to believe
this century will be different than the previous three. If a highly
infectious influenza virus begins to spread among humans
anywhere in the world, it will take less than three weeks to cross
the borders of the United States.
It is in our interest to help other nations develop disease-
monitoring systems and other tools necessary to protect their
citizens — and ours. Health diplomacy in that context is as much
self-interest as altruism. Our benevolence can produce benefits.
Health diplomacy improves the quality of our air and water.
When I headed the Environmental Protection Agency, I came to
understand the adverse impacts on our nation’s health that come
from pollutants that are generated in other countries and are
carried by prevailing winds to the United States. The black puff
of smoke coming from a factory in China or a tail pipe in Mexico
City may well be breathed in California or Maine.
The benefits of health diplomacy
go well beyond diplomatic points.
Health diplomacy also benefits
our citizens inside the United
States.
A community in Mozambique that
will benefit in clean water and
sanitation from the U.S. Government’s
Millennium Challenge Corporation.

9. Health Diplomacy: From the American People
7
Health diplomacy improves the quality of our food and medicine.
We are opening offices of the Food and Drug Administration
in China, India and Latin America, not just to inspect goods
but to work closely with the host governments to improve their
regulatory systems — not just out of benevolence, but because
we benefit.
A high percentage of our medications are now made in China
and India. Most of the fruits and vegetables consumed in the
United State during the winter months are grown in Central
America. The quality and safety of those products are enhanced
by our work in other nations.
Nicaragua is an example. In conversations with President
Ortega, I volunteered to bring a team of experts to help clean
up of Lake Managua, their primary water source. One morning
we spent several hours together on and around the lake. We got
into his jeep. He drove; I was his passenger. This was a good
diplomatic moment. I was there helping him solve a problem
critical to his country’s prosperity. Our work together helped
ensure that the food Americans eat is safe.
I spent part of a day vaccinating chickens against avian influenza
in Vietnam. Our nation was helping to protect poor farmers’
livelihoods. At the same time, we were protecting American
citizens against avian influenza.
Working together on mutually important problems in places
like Nicaragua and Vietnam creates relationships, trust and a
foundation to solve other problems. We need to broaden the
definition of health diplomacy to include more than patient care.
Water safety, health security, veterinary care, environmental
health — all of these are effective parts of health diplomacy.
There is another way health diplomacy benefits the United
States of America. Was it Mary Poppins who sang, “A spoonful
of sugar makes the medicine go down?”
The United States has a complex relationship with Pakistan.
We are important partners in the fight against terrorism. The
United States infuses billions into Pakistan every year in military
aid. However, for various reasons, our government is poorly
regarded by the Pakistani people.
It is in our interest to help
other nations develop disease-
monitoring systems and other
tools necessary to protect their
citizens — and ours.
We need to broaden the definition
of health diplomacy to include
more than patient care. Water
safety, health security, veterinary
care, environmental health — all
of these are effective parts of
health diplomacy.

10. Health Diplomacy: From the American People
8
I recently asked Sherry Rehman, who serves as both
Pakistani Minister of Health and Minister of Information,
if she thought people in Pakistan knew we give Pakistan
substantial help. She acknowledged they didn’t and
added, “I didn’t know until recently.” She said the U.S.
government is not well regarded among Pakistanis —
except in one region where the United States is quite
popular. It is in the northern part of Pakistan where a
massive earthquake struck in 2006.
The Minister went on to say, in essence, that people in the
region remember the image of U.S. helicopters that came
to their rescue in their hour of need. “The helicopters
are gone,” she said, “but the American people stayed
and helped them rebuild their communities.” In those
areas, well over two years later, more than 50 percent
of the people have a favorable impression of the United
States — a far cry from the fewer than 10 percent in other
regions.
I traveled the earthquake zone. There I met with the
leaders of small villages in the mountains still digging
out from their rubble. I saw the small health clinic we are
helping them build, and I met the health workers we are
training. The Minister is correct; we are well thought of
there.
A few weeks later, I read that American and NATO troops
had entered Pakistan territory, seeking to root out a high-
profile Al Qaeda leader hiding in the mountains. It was a
necessary use of hard power, one that would ultimately
benefit both of our nations. However, because of the
political situation in Pakistan, it was an action certain to
draw criticism from our critics there.
I’m guessing the reaction in the area of the earthquake
was not so harsh. Soft power builds trust for moments
when hard power is required. I think this is the reason the
Secretary of Defense feels so strongly about the need
to integrate hard power and soft power. This is another
example of health diplomacy combining benevolence with
benefit.
Health has become a significant tool in our foreign policy
apparatus across the government. The United States has
Soft power builds trust for
moments when hard power is
required.
We are benevolent ­— but we don’t
always benefit. We need to tell the
American story better.

11. Health Diplomacy: From the American People
9
dramatically increased our health diplomacy spending. Recently
authorized 5-year budgets represent 7-times-greater effort than
before the Bush Administration.
The State Department (USAID), the Departments of Defense,
Agriculture, and Health and Human Services, and the
Environmental Protection Agency, all contribute to the effort.
However, government activities are only part of the American
health-diplomacy picture. Thousands of U.S. non-governmental
organizations, corporations, universities, and private citizens,
provide assistance around the world. The combined government
and non-government assistance makes the United States the
most generous humanitarian force in human history. I’m fairly
sure much of the world doesn’t believe that.
I am confident that many of those who receive our nation’s
generosity don’t know it comes from us. We are benevolent –
but we don’t always benefit. We need to tell the American story
better.
Some American health initiatives are well known, like the
President’s Emergency Plan for AIDS Relief, or PEPFAR.
Similarly, The President’s Malaria Initiative, or PMI, is the
foundational piece of an impressive campaign among various
countries and civil societies to defeat malaria.
Congress has recently authorized a remarkable $48 billion over
the next five years for PEPFAR and PMI. History will conclude
that, in global health, President Bush has been noble, bold and
successful.
The next President should make health diplomacy an
overarching theme of foreign policy. The various efforts of
PEPFAR, PMI, and of USAID, the Department of Defense, HHS,
Agriculture, and the EPA, should be looked at as a combined
federal effort.
In addition, the President should reach out to the hundreds of
American non-govermental organizations (NGOs), faith-based
organizations, universities, corporations, foundations, and
individuals who are doing charitable health work outside the
borders of the United States today. A colorful banner should
be tied around all of our contributions, showing the world the
collective generosity and compassion of the American people.
The next President should make
health diplomacy an overarching
theme of foreign policy.
Spraying against malaria as part of the
residual spraying campaign in Zanizbar
funded by PEPFAR.

12. Health Diplomacy: From the American People
10
The President should issue a call to express our national
compassion as a choir, not as a collection of soloists. He should
ask all organizations whose work is paid for by the American
taxpayer to brand their efforts with a common message: “From
the American People.”
The phrase “From the American People” is currently being used
by USAID. I’m not suggesting any organization abandon its own
identity. I am suggesting there would be an enormous benefit
if we jointly built a reputation around these words. Imagine the
impact if those words, “From the American People,” began to
appear over and over again in countries we assist.
The most significant deficiency in U.S. government foreign-
assistance delivery is the abysmal job we do in branding
ourselves and our activities. This is true not only in health alone,
but across the board. Every agency of the federal government
has its own focus, and each jealously guards its own turf.
Often, these credit-claiming debates are resolved by affixing
multiple seals and symbols on material. Routinely, one sees
printed material with up to six different logos, each from a
different department or agency of the United States government.
This isn’t merely a complaint about bad aesthetics or design. It
compromises our ability to benefit from our benevolence.
For very good reasons, a great deal of federal aid is delivered
through non-governmental organizations (NGOs) all over the
world. Most NGOs do an excellent job, and they are a real asset.
Often the United States is overwhelmingly the largest partner or
exclusive funding source of an NGO, but one would never know
it. Services are almost always provided under the banner of the
NGO. Nearly all U.S. Ambassadors tell stories of going to events
where lavish praise lauds the goodness of an NGO, without a
word being said about the American citizens paying for it.
There are hundreds of small things that should add up to
our message. When patients are handed their anti-retroviral
medication, it should come in a bag bearing the words, “From
the American People.” When community health-workers we
train and pay for go house to house, they should carry a bag
displaying the phrase, “From the American People.” If that were
done, those sacks and bags would carry more than medicines—
they would carry a message from the people of the United
States.
Imagine the impact if those words,
“From the American People,”
began to appear over and over
again in countries we assist.
Community Clinic staff in Stone Town
Zanzibar. The Clinic is managed by the
Aga Khan Foundation in partnership
with the Revolutionary Government of
Zanzibar.

13. Health Diplomacy: From the American People
11
Picture the President of the United States at a clinic in Pakistan
as a mother gets prenatal services. Can you see the message:
“From the American People”? Can you envision what it does
for our country’s brand when the President, during a stop in El
Salvador, helps an American non-profit organization immunize
children against polio?
This is not a trivial matter. We need to benefit more from our
quietly abundant benevolence. Fixing the federal government’s
siloed approach to this can only be done by the President.
Fixing it a department at a time, won’t work. The next President
— early on — should implement a common branding strategy
across the government by Executive Order.
Let me acknowledge that there are situations where it
is imprudent for the symbols of the United States to be
represented on our aid. There are situations where doing so may
undermine a host government or even put those who render the
aid in danger. Those situations can be accommodated. What
cannot be tolerated in the future is the dilution of our foreign
policy goals and the brand-recognition we need to carry them
out.
When authorizing PEPFAR and PMI, Congress saw the virtue
of involving “non-traditional aid agencies.” The Departments of
Defense, Health and Human Services, and Agriculture, and the
Environment Protection Agency employ some of the best public
health professionals in the world. Included in the legislation was
a new novel model of a coordinator.
The Global AIDS Coordinator was given responsibility for
organizing and directing the multiple agencies and departments
that were already working globally on AIDS. The position has
unusual powers in determining funding priorities and resolving
interagency disputes. The coordinator system works, and the
new President should consider expanding its use.
Some people talk about creating a Department of Development.
This is a bad idea. Two Cabinet roles have taught me that
programs do better when they are supported across the
government, not merely by one Cabinet officer. A Department
of Development would isolate and compartmentalize health
diplomacy.
A colorful banner should be tied
around all of these contributions,
showing the world our collective
generosity and compassion of
the American people.
We need to benefit more from our
quietly abundant benevolence

14. Health Diplomacy: From the American People
12
Another way to improve our efforts is to leverage our symbols.
Previously, I mentioned our Navy hospital ships and the powerful
symbol they provide when they pull into the harbor of any
country. Other governments see the value of these symbols. You
might be interested to know the Chinese are building smaller
hospital ships because they can enter smaller ports.
Some worry that periodic visits are expensive and unsustainable.
The ship provides help and then leaves. But what such a ship
brings is the same powerful symbol that the Chinook helicopters
provided in Pakistan. It is the combination of memorable military
symbols and sustained on-the-ground efforts by American
NGOs and government agencies that sustains good feelings.
In summary, I have offered six suggestions to the next President:
Use health diplomacy to advance your other foreign-policy
goals;
Broaden health diplomacy’s definition to include water
quality, health security, veterinary care and environmental
health;
Unify the American brand by adopting the USAID banner,
“From the American People,” across the entire national
government;
Ask America’s taxpayer-financed NGOs, universities, faith-
based organizations, corporations, and individuals, to join
as a chorus of goodness, not a collection of soloists — and
highlight their activities;
Appoint U.S. global coordinators rather than
compartmentalizing our assistance within one government
department; and
Combine powerful symbols like Navy hospital ships and
military helicopters with sustainable on-the-ground efforts by
U.S. NGOs backed by government financial support.
In conclusion, I would offer our next President this advice:
Remember that the President is America’s most powerful
symbol. Embrace the power of health as a personal diplomatic
lever. Let the world see the goodness of America — by letting it
see the goodness of her most powerful citizen.
The next President—early on—
should implement a common
branding strategy across the
government by Executive Order.
1.
2.
3.
4.
5.
6.

15. In a global market there are three ways to approach
change. You can fight it and fail; you can accept it
and survive, or you can lead it and prosper.
We are the United States of America; let us lead.

16. What is past is prologue...